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Delayed Abdominal Aortic Aneurysm Repair after Thoracic Aortic Aneurysm Surgery: What is the Risk of Paralysis?
Brant W. Ullery, M.D., Grace J. Wang, M.D., Edward Y. Woo, M.D., Albert T. Cheung, M.D., Michael L. McGarvey, M.D., Jeffrey P. Carpenter, M.D., Ronald M. Fairman, M.D., Benjamin M. Jackson, M.D..
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

OBJECTIVE: To examine the results of open or endovascular abdominal aortic aneurysm (AAA) repair following prior open or endovascular thoracic aortic aneurysm (TAA) surgery.
METHODS: A retrospective review of a prospectively maintained database was performed in order to identify all patients who underwent open or endovascular AAA repair in a delayed fashion following prior open or endovascular TAA surgery at a single university hospital between 1999 and 2011. Patients requiring cardiopulmonary bypass for their abdominal aortic operation were excluded. Primary outcomes were mortality and spinal cord ischemia (SCI).
RESULTS: Thirteen patients were identified as having undergone AAA repair (open, n=6; EVAR, n= 7) following prior TAA repair (open, n=2; TEVAR, n=11). Mean age at initial thoracic aortic operation was 68.9 ± 6.9 years, and 77% (n=10) were male. Of the 11 patients who underwent TEVAR, 4 had extent C endovascular coverage (coverage of the entire descending thoracic aorta), and 4 patients had coverage of the left subclavian artery after prior left carotid-subclavian bypass. Three patients experienced transient delayed-onset SCI (paraplegia, n=2; paraparesis, n=1) following this initial thoracic aortic intervention; full recovery of neurologic deficits was evidenced in all three patients prior to discharge. The mean time interval between initial thoracic aortic surgery and subsequent AAA repair was 2.0 ± 1.8 years (range, 0.15 - 5.4 years). At the time of delayed AAA repair, 54% (n=7) had prophylactic lumbar drainage and 46% (n=6) had intraoperative somatosensory evoked potential monitoring. One patient who underwent EVAR had planned unilateral internal iliac artery coverage requiring coil embolization. Overall 30-day mortality was 0%. None of the patients demonstrated any neurologic deficits associated with SCI following their second aortic procedure. Kaplan-Meier survival at 1 year was 91% ± 9% with zero incidence of delayed SCI.
CONCLUSIONS: Delayed open or endovascular AAA repair following prior open or endovascular thoracic aortic surgery is technically feasible. This small series does not evidence any increased risk of perioperative mortality or SCI even in patients who had previously experienced transient SCI during prior thoracic aortic intervention. There is uncertain benefit to the routine use of prophylactic lumbar drainage in this unique patient cohort.


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